2
… safety must continue to be the highest priority in the planning and implementation of the future ATM system."

3
a) the dedication to safety by aviation organizations and their people b) a continuous learning process, based on safety information; and c) the ability to turn errors into preventive actions.

4
To be successful the industry must: - re-think methods of doing business - move beyond a blame culture that singles out individuals and criminalizes singles out individuals and criminalizes error(s) error(s)

5
… Just Culture can be described as an environment that is free from threat of punishment, does not focus blame on system components (operators), and ensures comprehensive and systematic safety occurrence reporting.

6
A culture in which front line operators or others are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.

7
1. it less likely that similar errors would be made again (Error Prevention), and 2. understanding the circumstances might make it possible to develop strategies to minimise the negative effect of the error (Error Recovery).

8
... that voluntary reporting systems are essential however, … we do not encourage incident reporting systems unless there is protection for the individuals who are providing the information.

12
Blame … * Focuses on defects of individuals, no account for all system components * Leads to defensive attitudes * Leads to defensive attitudes * Encourages an ineffective reporting system system * We learn from accident/incidents or punish individuals or punish individuals

13
criminalization of error is a key contributor to adversarial relationships. if it plays a role in incidents/accidents the real truth may never surface.

14
PUNISHMENT … characterizes humans as unreliable characterizes humans as unreliable emphasizes failure emphasizes failure concerned with closure concerned with closure about moving away from the event about moving away from the event

15
- The objective of any investigation is the prevention of accidents and/or incidents - The investigation process must not apportion blame or liability!

16
1) Error is a normal component of human performance performance 2) Human error cannot be avoided by designing it out of the system designing it out of the system 3) This fact must be incorporated into complex systems where safety is the complex systems where safety is the expected outcome. expected outcome.

18
d) Annex 6 Operation of Aircraft, paragraph 3.2.4, establishes that flight data analysis programs shall be non-punitive and shall contain safeguards to protect sources of data e) Annex 13 Aircraft Accident and Incident Investigation, paragraph 5.12, says: The State conducting the investigation of an accident or incident shall not make the following records available for purposes other than accident or incident investigation …

19
all statements taken from persons by the investigation authorities in the course of their investigation all communications between persons involved in the operation of the aircraft medical/ private information regarding persons involved in the accident/incident cockpit voice recordings and transcripts opinions expressed in the analysis of information

20
FROM … TO … A dont get caught cultureA dont get caught culture Few reports are madeFew reports are made Little systemic improvements occur Little systemic improvements occur An open cultureAn open culture Errors/incidents are reported for analysisErrors/incidents are reported for analysis Systemic improvementsSystemic improvements

21
threat of disciplinary action/regulatory enforcement is a major obstacle to reporting and investigation the role of disciplinary action must be addressed! must make better use of human error events